Carbon dioxide and pulsed dye laser treatment of angiofibromas in 29 patients with tuberous sclerosis

BACKGROUND: Data on the benefits, adverse effects and appropriate types of laser treatment for angiofibromas (AF) in patients with tuberous sclerosis (TS) are limited. OBJECTIVES: To evaluate the efficacy and side-effect profile of carbon dioxide (CO2) 10,600 nm wavelength and flashlamp-pumped pulsed dye (FLPDL) 585 nm wavelength lasers in a retrospective study of 29 patients with TS aged 9-48 years. METHODS: Long-term results, based on clinical improvement of the vascular, fibrous or protuberant types of AF and the presence or absence of side-effects on follow-up visits, were classified as excellent, moderate or poor. RESULTS: Results were excellent in most patients with vascular-type AF treated with one or two sessions of FLPDL, but some required up to six treatment sessions. CO2 lasers produced excellent results with considerable long-term improvement in 10 of 13 (77%) patients with fibrous or protuberant AF, specifically in all (three of three) protuberant and 70% (seven of 10) of fibrous AF. Persistent hypertrophic scarring was seen in three of 13 (23%) patients with either fibrous or protuberant AF treated with the continuous wavelength CO2 laser. Treatment with both lasers used in four patients with combined vascular and non-vascular AF components was excellent in three of four (75%) patients. Significant relapse was seen in one patient treated with the CO2 laser. CONCLUSIONS: CO2 or FLPDL laser treatment should be considered as an effective treatment for patients with disfiguring TS. A combination of lasers may be required to achieve optimal results.     

Treatment of angiofibromas of tuberous sclerosis with carbon dioxide laser vaporization

The therapeutic approach to angiofibromas in tuberous sclerosis is a challenge for the Dermatologist. The latest treatment modalities include use of argon and carbon dioxide lasers. We describe the ease of an 18-year-old Caucasian boy with multiple angiofibromas on the face, treated with CO₂ laser with good cosmetic results.     

Topical 0.1% rapamycin for angiofibromas in paediatric patients with tuberous sclerosis: a pilot study of four patients

Tuberous sclerosis complex (TSC) is an autosomal dominant genodermatosis characterised by the development of hamartomatous tumours in multiple organs including the brain, skin, kidneys, heart and lungs. Facial angiofibromas are the most visible and unsightly of the cutaneous manifestations of TSC, often resulting in stigmatisation for both the affected individuals and their families. Current treatments include vascular laser, ablative lasers and other destructive techniques such as shave excision and electrodessication. For the best outcome these treatments have to be repeated throughout childhood and teenage years, necessitating multiple general anaesthetics. We report a pilot study of topical rapamycin in four children with TSC and facial angiofibromas. Two patients were trialled on 0.1% rapamycin in petrolatum and the other two patients with 0.1% rapamycin solution (Rapamune) applied topically. Both preparations were rapidly and equally effective, however the 0.1% in petrolatum was much better tolerated. Younger patients with smaller angiofibromas had the best response with near complete clearance. Both preparations were more cost effective than pulsed dye laser under general anaesthesia. Although larger studies are needed, this treatment shows a potential to be a first-line management for facial angiofibromas in TSC and appears safe to start in early childhood.     

Topical rapamycin for angiofibromas in paediatric patients with tuberous sclerosis: Follow up of a pilot study and promising future directions

One of the most visible and potentially disfiguring cutaneous manifestations of tuberous sclerosis complex is the development of multiple facial angiofibromas, present in over 80% of patients. Topical rapamycin has been shown in many reports to be a safe and effective treatment for facial angiofibromas. In February 2012 we reported the results of a pilot study of four patients undertaken at a paediatric tertiary hospital in Australia. Since then, we have continued to refine the optimal formulation and concentration of topical rapamycin and expanded our selection of patients. We present an update on our current cohort of treated patients, discuss the optimal formulation of topical rapamycin and include a literature review on all published cases to date. Although topical rapamycin is not a curative treatment, we have demonstrated that its early institution significantly reduces both the vascularity and palpability of angiofibromas and prevents their progression with age. It is well tolerated and now a cost effective option.     

Comparison of microinsulated needle radiofrequency and carbon dioxide laser ablation for the treatment of syringoma

Syringoma is a benign adnexal tumor originating from the intradermal eccrine ducts and predominantly occurs in women at puberty or later in life. We present a case of a 30‐year‐old woman with a 2‐year history of syringoma on her neck and axillar region. She was treated with two devices in a split manner. The right‐sided lesions of the neck were treated with one session of 10,600‐nm carbon dioxide (CO₂) laser ablation. The left‐sided lesions were treated with microinsulated needle radiofrequency (RF) three times. After treatment, the lesions treated with CO₂ showed hypertrophic scar formation, but the other side lesions treated with microinsulated needle RF showed a marked reduction in the size and number of lesions, without any adverse effects such as scarring and hyperpigmentation related to epidermal damage. The treatment of syringoma with microinsulated needle RF, which is insulated at the point of epidermal contact, results in good cosmetic outcomes. Syringoma, microinsulated needle RF, CO₂ laser.     

Carbon dioxide laser treatment of rhinophyma: a review of 124 patients

Background  Rhinophyma is a progressive, localized or generalized nasal deformity resulting from hypertrophy of sebaceous and connective tissue. The CO₂ laser has been used for treatment of rhinophyma, but the long-term efficacy of the treatment is unknown.
Objectives  To review the outcome of 124 patients with rhinophyma treated with the CO₂ laser between 1996 and 2008 in our centre.
Patients and methods  Exuberant sebaceous tissue was ablated using the Sharplan 40C CO₂ laser (Sharplan Lasers UK Ltd, London, U.K.) under local anaesthesia. The technique varied with the severity of rhinophyma; the laser was used in a continuous mode to debulk the larger rhinophymas, and in a resurfacing mode (Silk Touch^® scanner; Sharplan, 4–7-mm spot at 20–40 W) or continuous mode (10–20 W using a defocused 2–3-mm beam) to reshape the nasal contours. Outcomes were determined by case notes, clinical review and questionnaire.
Results  Laser treatment was completed in a single session in 115 of 124 patients. All patients were reviewed 3 months post-treatment. Results were classified as good to excellent in 118 and poor in six patients. All patients were sent a satisfaction questionnaire in 2008 and 52 patients replied. Patients reported high levels of satisfaction following treatment. The post-treatment response at 3-month review was maintained long term. The main complications were pain associated with injection of local anaesthetic, scarring and hypopigmentation (four patients) and open pores (two patients).
Conclusions  The CO₂ laser is an effective and durable treatment for rhinophyma. Treatment carries a low risk of side-effects and is associated with high patient acceptability and satisfaction.     

A Case of Tuberous Sclerosis with a Giant Angiofibroma

This is a case study of tuberous sclerosis with unusually large facial angiofibromas. The patient had other intense skin manifestations. Histological findings in the angiofibroma included large and glial-appearing cells specific for this disease. Karyotype analysis revealed a translocation of chromosome (12q^–, 15q⁺).     

Venous malformations with lip involvement: Palliative treatment with carbon dioxide laser vaporization in five cases

Background: The treatment of venous malformations remains controversial. Traditional surgical excision is only possible in a few cases. Numerous sclerosing agents have been used, but none of them are ideal or absolutely safe for the treatment of venous disorders. In isolated cases, an expectative control would be a good option. Objective: To report our experience with CO₂ laser vaporization as palliative treatment in five cases of head and neck venous malformations with lip involvement. Methods: Five patients were treated with a CO₂ laser in superpulsed, focused mode at 2?W/cm², with several passes in each session. Patients were aged from 16 to 49 years old (mean: 36.6 years). Three sessions of treatment were performed in two patients while only one session was used in the rest. The follow‐up was 6–36 months (mean: 22.8 months). Results: Significant cosmetic improvement with flattening of the lip surface was achieved in all patients. Conclusion: Carbon dioxide laser vaporization can be considered as one method of choice for an effective palliative treatment of lip involvement in venous malformations.     

Burn scars treated by pinhole method using a carbon dioxide laser

Many patients with burn injuries have various complications and emotional problems due to scars. Although various modalities to improve burn scars have been attempted, such as excision of scars, skin grafts, laser abrasion and silicone product usage, the cosmetic outcomes have not been satisfactory for a large portion of patients. Herein, we describe two cases which showed satisfactory cosmetic results after treatment of burns scars with the pinhole method using a carbon dioxide (CO(2)) laser that allowed us to make deep, closely set holes reaching down to the upper dermis. A 20-year-old female patient with a scar on her neck and a 25-year-old female patient with a scar on her right forearm after burn injuries are presented. As early as only a few weeks after the treatment, the scars showed relaxation of contracture, reduction of wrinkles and improvement of texture and color compared to before the treatment. Treatment of burn scars with the pinhole method can be easily performed and results in dramatic improvement in scar quality with only a few side-effects.     

Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser

Background Hidradenitis suppurativa (HS) is a chronic and often a recalcitrant inflammatory skin condition. Objectives To present the results of carbon dioxide (CO₂) laser treatment of recalcitrant HS in nine patients who had failed to improve on medical and other surgical treatments. Methods HS lesions consisting of abscesses, sinuses and granulation tissue were completely excised using the cutting mode of a CO₂ laser, leaving only healthy residual subcutaneous fat. The wounds were closed by primary intention where possible and left to granulate otherwise. Outcomes were determined by clinical review and questionnaire. Results Twenty‐seven sites were treated in 19 sessions on nine patients. Seven procedures were performed under general anaesthesia and 12 under local. All patients rated their postoperative discomfort as less or equal to their preoperative state. Seven of the nine patients had complete remission for 12 months or longer after their last laser treatment and ceased all medications. High levels of patient satisfaction were reported with CO₂ laser treatment. The main complication was axillary scar contracture in two patients but this was insufficient to limit limb movement. Conclusions CO₂ laser treatment should be considered as a treatment option in recalcitrant HS, where multiple medical treatments have been ineffective.     

CO2点阵激光治疗无色素痣一例首次报道

无色素痣（ND）以往采用308 nm准分子激光或光照射、自体表皮移植等治疗方法取得了一定的疗效,未有报道单用CO₂点阵激光治疗的病例。本篇首次报道1例单用CO₂点阵激光治疗ND的病例,4次治疗后基本复色,无明显不良反应。     

Ultrapulse carbon dioxide laser treatment for bilateral facial nevus comedonicus: A case report

Nevus comedonicus (NC), a rare skin ailment with an aggregation of dilated follicular orifices filled with keratinous material, is difficult to treat. Several drugs have been assessed for the treatment of NC, but with limited success. Surgery requires much experience and the recurrence rate is high. Various types of laser have been tried, with promising outcomes. A 54‐year‐old male patient with bilateral facial NC was admitted on July 8, 2014. A coin‐sized area was first treated successfully with ultrapulse CO₂ laser. The remaining lesions were treated during three subsequent sessions at 2‐week intervals. There were no complications. There was no recurrence after 2 years. This case suggests that ultrapulse CO₂ laser could efficiently alleviate NC. Ultrapulse CO₂ laser treatment should be further studied for its application in the treatment of NC.     

Treatment of fibroelastolytic papulosis with fractionated carbon dioxide laser

Fibroelastolytic papulosis (FEP) is an acquired elastic tissue disorder that presents as white-to-yellow papules and plaques usually occurring on the neck. Although the lesions are often asymptomatic, their appearance may be distressing to patients. FEP has been treated with topical tretinoin in one case report (1 Wang AR, Lewis K, Lewis M, Robinson-Bosom L. Papillary dermal elastosis: a unique elastic tissue disorder or an unusual manifestation of pseudoxanthoma elasticum- like papillary dermal elastolysis? J Cutan Pathol. 2009;36: 1010–1013.[Crossref] , [Google Scholar]). Other reports have not mentioned treatment for this rare disorder (1–6 Wang AR, Lewis K, Lewis M, Robinson-Bosom L. Papillary dermal elastosis: a unique elastic tissue disorder or an unusual manifestation of pseudoxanthoma elasticum- like papillary dermal elastolysis? J Cutan Pathol. 2009;36: 1010–1013. Rongioletti F, Rebora A. Fibroelastolytic patterns of intrinsic skin aging: pseuodoxanthoma-elasticum-like papillary dermal elastolysis and white fibrous papulosis of the neck. Dermatology. 1995;191:19–24. Shimuzu H, Kimura S, Harada T, Nishikawa T. White fibrous papulosis of the neck: a new clinicopathologic entity? J Am Acad Dermatol. 1989;20:1073–1077. Balus L, Amantea A, Donati P, Fazio M, Giuliano MC, Bellocci M. Fibroelastolytic papulosis of the neck: a report of 20 cases. Br J Dermatol. 1997;137:461–466. Jagdeo J, Ng C, Ronchetti IP, Wilkel C, Bercovitch L, Robinson-Bostom L. Fibroelastolytic papulosis. J Am Acad Dermatol. 2004;51:958–964. Ohnishi Y, Tajima S, Ishibasi A, Inazumi T, Saski T, Sakaoto T. Pseudoxanthoma elasticum-like papillary dermal elastolysis: reposrt of four Japanese cases and an immunohistochemical study of elastin and fibrillin-1. Br J Dermatol. 1998;139:141. ). We present a case of FEP successfully treated with a fractionated carbon dioxide (CO₂) laser.     

Treatment of recalcitrant warts with the carbon dioxide laser using an excision technique

Abstract

Recalcitrant warts remain a challenging problem to treat, with considerable morbidity for patients. Our technique uses the carbon dioxide (CO2) laser as a bloodless scalpel to excise and treat recalcitrant warts. This paper reviews the results of patients with recalcitrant warts treated by the senior author using this technique. Methods. A retrospective case note review and questionnaire-based survey of patients treated by this technique. Results. Seventy-one recalcitrant warts treated in 22 patients, all as day case procedures. A total of 54.5% of patients had complete remission after one treatment and the average length of follow-up was 71.5 months. Recurrence occurred on average 5.29 months following treatment. Of those patients, 90% were successfully retreated, giving an overall rate of 95.5%. In total, 46.7% of patients were left with scarring, but all felt this was acceptable given the benefits of the treatment, and 80.0% of patients would have the procedure again. Four patients had spontaneous regression of warts at other body sites not treated with the CO2 laser. Conclusion. This study illustrates the efficacy of our technique with a favourable outcome comparable to published studies. Recurrence occurred within 12 months; therefore, we would recommend this as a minimum follow-up period. In addition, the disappearance of warts at distant sites suggests that the effects of the CO2 laser therapy modulate the immune system, thereby extending it beyond simple excision or ablation.     

Fractional carbon dioxide laser in recalcitrant vulval lichen sclerosus

Vulval lichen sclerosus is an uncommon skin condition that can usually be managed with topical corticosteroids to maintain remission. However, there is a subset of patients in whom it remains recalcitrant despite treatment with super‐potent topical corticosteroids. We report a case series of four patients undergoing fractional carbon dioxide laser resurfacing and one with ablative carbon dioxide laser for severe, hyperkeratotic vulval lichen sclerosus not responding to super‐potent topical corticosteroids. In these patients, carbon dioxide laser was successful in achieving remission. Their vulval lichen sclerosus was subsequently able to be maintained with topical corticosteroid treatment.     

Scarring of lupus miliaris disseminatus faciei: treatment with a combination of trichloroacetic acid and carbon dioxide laser

We present a case of a 35‐year‐old man having a 12‐month history of multiple reddish‐brown papules on the chin, forehead, cheeks, and eyelids. Histopathologic findings revealed epithelioid cell granulomas with central necrosis consistent with a diagnosis of lupus miliaris disseminatus faciei. After 9 months of combined treatment with ethambutol, rifampin, and pyrazinamide, most lesions gradually resolved but remained as severe disfiguring scars. After 10 sessions of treatments with 100% trichloroacetic acid and CO₂ laser, the lupus miliaris disseminatus faciei scars have been much improved and the patient has never experienced a recurrence of disease during subsequent years of follow‐up.